Nursing Elites

1. What are the key signs of respiratory distress?

• A. Increased respiratory rate and use of accessory muscles
• B. Decreased respiratory rate and cyanosis
• C. Cyanosis and use of accessory muscles
• D. Altered mental status and bradycardia

Correct answer: A

Rationale: The correct answer is A: Increased respiratory rate and use of accessory muscles are key signs of respiratory distress. When a person is experiencing respiratory distress, their respiratory rate typically increases as the body tries to compensate for the inadequate oxygenation. Additionally, the use of accessory muscles indicates that the person is working harder to breathe. Choices B, C, and D are incorrect because they do not accurately represent the key signs of respiratory distress. A decreased respiratory rate, cyanosis, altered mental status, and bradycardia are not typical signs of respiratory distress.

2. A client is undergoing radiation therapy. Which of the following actions should the nurse take to prevent skin irritation?

• A. Apply heat packs to the area
• B. Use perfumed soap to cleanse the area
• C. Keep the area moist with lotion
• D. Avoid sun exposure to the treated area

Correct answer: D

Rationale: Avoiding sun exposure is crucial to prevent skin irritation and burns in clients undergoing radiation therapy. Radiation therapy makes the skin more sensitive to sunlight, increasing the risk of skin damage. Applying heat packs (choice A) can exacerbate skin irritation as heat can further irritate the skin that is already sensitive due to radiation. Using perfumed soap (choice B) can further irritate the skin due to its harsh chemicals, potentially worsening skin reactions. While keeping the area moist with lotion (choice C) may seem beneficial, some lotions contain ingredients that can worsen skin reactions during radiation therapy. Therefore, avoiding sun exposure to the treated area (choice D) is the most appropriate action to prevent skin irritation and damage during radiation therapy.

3. A nurse is caring for a client who has been experiencing chronic pain. Which of the following interventions should the nurse implement?

• A. Provide the client with distractions such as television
• B. Administer pain medication around the clock
• C. Teach the client relaxation techniques
• D. Perform massage therapy on the client

Correct answer: C

Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques. This helps the client manage pain more effectively by reducing stress and anxiety, which can contribute to the perception of pain. Providing distractions like television (Choice A) may offer temporary relief but does not address the underlying issue of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote holistic pain management. Massage therapy (Choice D) can be beneficial but may not be as effective as teaching relaxation techniques in the long term for managing chronic pain.

4. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury for this client?

• A. Use a bed exit alarm system
• B. Raise all four side rails while the client is in bed
• C. Apply one soft wrist restraint
• D. Dim the lights in the client's room

Correct answer: A

Rationale: Using a bed exit alarm system is crucial in minimizing the risk of injury for a client with dementia. This intervention helps alert staff when the client is attempting to leave the bed, reducing the chances of falls. Raising all four side rails while the client is in bed (Choice B) can lead to restraint-related issues and is not recommended unless necessary for safety reasons. Applying a soft wrist restraint (Choice C) is generally not the first choice in managing clients with dementia due to the risk of complications and loss of mobility. Dimming the lights in the client's room (Choice D) may not directly address the risk of injury associated with dementia and may even increase the risk of falls due to poor visibility.

5. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?

• A. Inject the medication into the muscle of the thigh
• B. Massage the injection site after administration
• C. Pinch the skin before injecting
• D. Administer the medication at the same time each day

Correct answer: C

Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.

Similar Questions